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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY!ENVIRONMENTAL HEALTH DEPARTMENT 1869 EAST HAZELTON AVENUE-STOCKTON GA 95246-(209)455-3120 <br /> NON-RIEFUll PERMIT- CALL(209)953-7697 FOR INSPECTIONS iExPIRES I YEAR FROM DATE 155U?O <br /> : 35035 S CORRAL HOLLOW Rd Tracy,CA x53777 <br /> gas <br /> sin,on tenlos 6105522574,1,107144115 <br /> 36768iiiiesblvd fremont-194536 <br /> v <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONT.ACTOR ADDRESS CITYISTATEMP <br /> u C-57 n C-61 ci D-OO cj 011101� 434219 <br /> DOMESTIC WELL SAMPLING;LJ General Polinaral/Gollf0ml Eacfteria(4291)1- Dibromouhloropropane(4292)D Areanic(4202) <br /> Dornestlet"Vat, F1 irrigaflon/AgrICUltuml L InjuStIal rl Water QUOIlty Maniaing D Solt 2M In )Qra r=on <br /> C-Ptj�JiC Wet&system <br /> eorUd Name.1Pt­t Number <br /> N—well F',Repk4w(nent Wall 0 Well AllarationlModiTication D other _. <br /> Monitoring Wrl(S)_#of wells C soil B.nnq(s)— Mafbr.rp- Ll Geolectinic.; <br /> Of-S ' Well c Out-Of-Service Well Renewal �j Repair <br /> O <br /> � ,"Trv,W 0 Pump R I acammt Z Pum Repair ❑Raise Wall 4r <br /> Drilling Metnua D Mud Rotary C Air Rotary 0 Auger Ll CQblc Tool L PLIah Point 0 Oth <br /> Proposed Wctl Depul ft Ex—atur,' in diameter E, Open Bottom CI Gravel PacklGraval Sjqe.in diameterConductor Casing_in(IlarnsIgr I Conductor CASing Depth <br /> ft <br /> Well Casing Diameter_in Thicknass/GaugrJASTM Schad— 0 Steel 0 Pf3slic [I Stainless Steel L:Other_ <br /> Grout sea] Drpth_rt 0 NoAt Cement(94 10 bqgl�10 gal wqtter) 0 Sand COMCM—w-k mix17 gal water <br /> E Bentonite(20%solids) 0 r)lhfj <br /> Gr(jut Placement Method LJ Pumped Cl Free I'all U other 0 Retardant I Accelerator(name) <br /> lilili4-4. Installed By t7 Driller Pump Contr4aor CJ Other in 0 Stove Pipe <br /> Pedestal OD mel alon.:Wdtln ft Lengthft ThickJ;L.�450 <br /> 0 bubmcrt-Mail Turbine G Other #fAr 470 <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORnANCE WITH SAN <br /> J1jAQUIN'G0UNTY ORDINANCES. STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT My REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CQNTRAcTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> Trp owneryy;a3ltA11rJ <br /> ————————————— <br /> PA <br /> - --- ----- iv? <br /> --- ---- 2019 <br /> CO Py <br /> FT <br /> FNt <br /> DgR E N�U�ry <br /> j!D <br /> Gtr <br /> )0 <br /> AL�ceple�BY Employee 1 CW <br /> Date ❑�PECIAL Well Permit <br /> Grout Inspection By <br /> ss <br /> Pump ft.spefton'By Dale .0 WAIVER Received <br /> Constructed Well Depth It <br /> f;.il goring t�nsp6 0'.Ely Date <br /> COMMENTq <br /> F—PE I SC ROCOivv# Cir lrJfJ Amount Date PeTanw: Inv-i-# Wall ID* <br /> Codes, Info 8 ash R Itted <br /> WELL fPIJMP MikMrr <br />